Care Home: Northgate House

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What the care home does well The home was clean and warm and there were different areas for people to sit in. There was a refurbishment/redecoration plan in place with ongoing renewal of the fabric of the home. There were sufficient staff on duty in terms of numbers and people commented positively about their approach, `they look after us well` and `the helpers are good`. Staff were enthusiastic about their role and one person commented, `I enjoy working here`. The staff tried to ensure that people made some choices about aspects of their lives such as where to sit during the day, what meals to have and when to rise and retire. A relative told us that they were always made to feel welcome when they visited and they were kept informed. People liked the meals and stated they were well presented. The menu is on display so residents are aware of what meals are available. The number of staff that had gained a national vocational qualification in care was 68%, which was a very good achievement. New staff members were recruited well and all checks were carried out prior to the start of employment. What has improved since the last inspection? The home did not receive any requirements at the last inspection. Communication has improved to ensure that information about residents` needs from one shift is documented and passed on to the next. Since the last inspection the front lounge, dining room and four bedrooms have been redecorated. The dining room is to have a new carpet next week. What the care home could do better: The home needs to ensure that all assessment information is available to them prior to people being admitted to the home. This will ensure that staff have full information about people in order to decide if their needs can be met there. The care plans could contain more information about people and ensure that all needs are recognised so care won`t be missed. There could also be an improvement in daily recording, for example of hygiene charts, monitoring records and key worker activity. People using bed rails must have a risk assessment that takes into account the actual need for them and that they are the right ones for the person and the bed they are using. The bed rails also need to be checked when used so they remain safe. A staff member did not follow guidance, policies and procedures and indeed their training when supporting a resident. It is important that people are listened to and their wishes acknowledged. This will improve the confidence residents and relatives have that their health needs will be met promptly. Medication practices must improve to ensure people receive their medication as prescribed. People told us that there was not a lot of activities provided. There were some documented but clearly the home has not got it quite right for everyone. People with dementia need to have their social needs assessed so occupational stimulation can be tailored to meet their changing needs. The communal conservatory corridor could be improved, as the carpet was very stained in places and during the heavy rain we noticed one section had a small leak. There needs to be hand paper towels in all communal toilets to prevent the spread of infection. Staff have access to mandatory training, dementia care and training in the conditions affecting older people. The training log needs to reflect this additional training and the dates it was completed. The induction that staff receive could evidence competence more clearly before being signed off by senior staff. The quality assurance checks could be broadened so that visiting professionals and staff have a say in the services provided and audits such as medication, need to be completed thoroughly so the home picks up the issues that we did during our site visit. Although staff do receive some formal supervision the amount they receive should be increased to at least six sessions a year. This will enable their work to be monitored, training to be identified and issues to be discussed. The manager stated that staff did receive the supervision but the log had been misplaced and a new one was to be organised. Key inspection report Care homes for older people Name: Address: Northgate House 92 York Road Market Weighton York East Yorkshire YO43 3EF     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Beverly Hill     Date: 0 3 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Northgate House 92 York Road Market Weighton York East Yorkshire YO43 3EF 01430873398 01430871706 northgatehouse@supanet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr John Keith Chambers,Mrs Jean Chambers,Miss Elizabeth Joy Chambers Name of registered manager (if applicable) Mrs Jean Chambers Type of registration: Number of places registered: care home 25 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Northgate House is registered to provide residential, personal, and social care for 25 people over the age of 65 years, including people with dementia. The home is a large house that has been extended to meet the demand of a growing local population. The home is located close to the centre of Market Weighton and provides good access to the towns services and amenities. The home was first registered in 1984 and was acquired by the present owners in September 1998. The registered providers are Mr and Mrs Chambers and their daughter Miss Chambers. Care Homes for Older People Page 4 of 32 Over 65 25 25 0 0 1 9 0 5 2 0 0 9 Brief description of the care home The home has four lounges and a dining room, which provides people with various places to sit. There is a shower room, two assisted bathrooms and sufficent toilets within easy access to communal areas. The home has nineteen single bedrooms and three shared bedrooms. Eleven of the bedrooms have en-suite facilities. There is a well-tended garden and patio area located at the rear of the premises that provides a safe and secure area for the residents walk around, sit, or enjoy activities. There is a car park for staff and visitors. All areas of the building are accessible to residents via the use of ramps and two stair lifts. The home has an information pack and service user guide to inform prospective residents about the home. The fees for the home ranged from £375-£545 per week. Additional charges are made for chiropody and hairdressing. The manager discusses the service user guide with prospective people, which includes the range of services available and the terms and conditions of stay. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means that the people that use this service experience adequate quality outcomes. This inspection report is based on information received by the Care Quality Commission (CQC) since the last key unannounced inspection on 19th May 2009 and a site visit to the home, which lasted approximately eleven hours. We had concerns about the home following a complaint and safeguarding alerts received by the local authority. We wanted to ensure that people living in the home were being well looked after so we altered our inspection schedule and completed a site visit. Throughout the day we spoke to people that lived in the home to gain a picture of what life was like at Northgate House. We also had discussions with the registered Care Homes for Older People Page 6 of 32 manager/proprietor, a staff member and two relatives. We left some surveys for staff members to complete. We received surveys from six residents, a relative and two staff members. Comments from discussions and surveys have been used throughout the report. We looked at assessments of need made before people were admitted to the home, and the homes care plans to see how those needs were met while they were living there. Also examined were, medication practices, risk management, activities organised, nutrition, complaints, staffing levels, staff training, induction and supervision and how the home monitored the quality of the service it provided. We also checked to see how residents were consulted with in how the home was run and how privacy and dignity was maintained. We also wanted to be sure that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. We observed the way staff spoke to people and supported them. The provider had returned their annual quality assurance assessment (AQAA) within the required timescale. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We would like to thank the people that live in Northgate House, the staff team and management for their hospitality during the visit, and also thank the people who had discussions with us. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at significant risk of harm. In future if a requirement is repeated it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: The home needs to ensure that all assessment information is available to them prior to people being admitted to the home. This will ensure that staff have full information about people in order to decide if their needs can be met there. The care plans could contain more information about people and ensure that all needs are recognised so care wont be missed. There could also be an improvement in daily recording, for example of hygiene charts, monitoring records and key worker activity. People using bed rails must have a risk assessment that takes into account the actual need for them and that they are the right ones for the person and the bed they are using. The bed rails also need to be checked when used so they remain safe. A staff member did not follow guidance, policies and procedures and indeed their training when supporting a resident. It is important that people are listened to and Care Homes for Older People Page 8 of 32 their wishes acknowledged. This will improve the confidence residents and relatives have that their health needs will be met promptly. Medication practices must improve to ensure people receive their medication as prescribed. People told us that there was not a lot of activities provided. There were some documented but clearly the home has not got it quite right for everyone. People with dementia need to have their social needs assessed so occupational stimulation can be tailored to meet their changing needs. The communal conservatory corridor could be improved, as the carpet was very stained in places and during the heavy rain we noticed one section had a small leak. There needs to be hand paper towels in all communal toilets to prevent the spread of infection. Staff have access to mandatory training, dementia care and training in the conditions affecting older people. The training log needs to reflect this additional training and the dates it was completed. The induction that staff receive could evidence competence more clearly before being signed off by senior staff. The quality assurance checks could be broadened so that visiting professionals and staff have a say in the services provided and audits such as medication, need to be completed thoroughly so the home picks up the issues that we did during our site visit. Although staff do receive some formal supervision the amount they receive should be increased to at least six sessions a year. This will enable their work to be monitored, training to be identified and issues to be discussed. The manager stated that staff did receive the supervision but the log had been misplaced and a new one was to be organised. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensured that peoples needs were assessed prior to admission. However, not obtaining assessments completed by the local authority, for people funded by them, means that the home may not have full information about people in order to make a decision about whether their needs can be met. Evidence: We looked at four care files during the day, one of which was for a resident recently admitted to the home. We wanted to check the admissions process and to find out what information the home received prior to admission. We were told that staff had visited the resident in hospital and gained sufficient information to make a decision that their needs could be met in the home. The assessment was particularly important, as the person was funding their own care and there would be no assessment completed by the local authority. Care Homes for Older People Page 11 of 32 Evidence: The date on the assessment documentation was three days after admission, which looks as if the assessment was completed after the person became a resident. However, we accepted the explanation that notes were made during the visit to the hospital and these were later transferred to the assessment documentation. To improve, the assessment documentation, which offers prompts for staff, should be used when visiting any potential resident to avoid missing any vital information. The assessment covered all areas of health and personal care and gave some background to the reason for admission into the home. A care plan was produced for the resident within two days of admission. The home wrote to residents or their representatives following the assessment stating that, having regard to the assessment, the persons needs could be met in the home. Two additional in-house assessments completed by staff were examined. It was noted that dates of completion, and signatures of the person completing the assessment and the resident/relative were missing. It is important to sign and date the documents for future reference. Signatures of the resident or relative also evidence their agreement and participation in the process. The manager advised that the local authority do not always make available the assessments completed by care management prior to a residents admission. It is important that these assessments are received for decision-making purposes. The manager was advised to speak with the care management teams to address this. The home does not provide intermediate care services so standard 6 does not apply. Care Homes for Older People Page 12 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were positive about the care they received. However, some care and risk management plans need further development so that peoples needs are met. The management of medication was not sufficiently robust to ensure all residents received their medication as prescribed. Evidence: We looked at four care plans in detail and also checked monitoring records for particular residents. The home used a standex system for care plans and those seen generally contained information about peoples needs. Some were more personalised than others with the specific details about how the residents wished to be cared for and the tasks staff needed to carry out. There are some improvements that can be made to the plans of care and the support provided by staff. For example, some areas of risk had been identified but not planned for. One person had reduced mobility and continence issues but there was no care plan to monitor their skin condition. The physiotherapist had visited the person the Care Homes for Older People Page 13 of 32 Evidence: day before the inspection and recommended they sit on a cushion, which had been ordered for them, so there was a significant risk of tissue damage. The records state that one resident had risks associated with their behaviour, which could become challenging for staff. The assessment stated they could become, very aggressive and very forgetful. However, the care plan did not reflect this and there was no detail on what form the behaviour took and what approaches staff were to use to manage it consistently. The same resident had clear risks associated with their nutritional intake and the dietician had visited and provided information about their diet. The care plan had not been updated with this information, records showed the person was gradually losing weight and their nutritional intake was not being monitored. The dietician requested that weights were carried out weekly but records showed that this was completed monthly. They also had nocturnal disturbances and slept all day during the visit missing breakfast and lunch. We were told that this was a regular occurrence. The care plan states that the person sleeps well at night and so need updating. We checked at tea time and the resident had eaten their tea. However, this was a light meal of scrambled egg and sausage, as the main meal of the day was at lunch. The handover sheet did state that food was provided in the night but not what this was or the amounts. As the dietician had requested a fortified diet with lots of milky puddings and drinks we have advised the manager to keep a clear record of nutritional intake for information for the dietician on their next visit. The staff recorded that they had reviewed the care plans and there was some evidence of updates when needs changed. Evaluations took place monthly but these were not a check that the care plan was working effectively but were goal statements for each section of the care plan. To improve, evaluations should be thorough and take into account information recorded in other areas of the care file, for example, accident records, visits by health professionals, monitoring charts and daily recordings. Not all care plans were signed and dated by the person formulating them and by the resident or their representative. People spoken with could not remember if they had seen their care plans or had them explained to them but they did state that staff looked after them well. Six surveys were received from people living in the home. Four stated that they, always received the care and support they needed and that staff were always available and listened to what they had to say. One person said this was , usually and another said this was, sometimes. A relative stated in a survey, they have improved her diet - we also know that she is taking her medication at the correct time. In a discussion with the Care Homes for Older People Page 14 of 32 Evidence: relative they also stated, if there is a medical problem they would sort it out and will keep us well informed. The home had improved the way the staff passed on information to each other. Separate handover sheets were completed for day and night care and a comment was made for each resident which detailed any significant issues. Other daily recording was not quite as consistent. Some staff were more comprehensive than others in completing key worker notes, there were gaps in hygiene records and food monitoring charts and we could see no activities recorded in the individual records we examined. There was evidence that people had access to health care professionals such as doctors, community nurses, a physiotherapist for one resident, chiropodists and hospital consultants. There had been an incident since the last inspection when a resident requested medical assistance or their family as they stated they were unwell. The staff member on duty did not take note of this request. This has been investigated as a complaint by the local authority. It is important that staff listen to people and contact professionals for advice if they are unsure about medical conditions. The staff completed risk assessments for any area they judged as posing a concern. These included falls and slips, moving and handling, nutrition, pressure relief and potential scalds from hot water. We noted in one residents care file that important dietary information, identified as high risk, had not been included in the care plan. The bed rail risk assessment needs to reflect health and safety guidance. This is discussed in the management section of the report. We examined the way the home managed medication by looking at receipt, storage and administration. The home used a monitored dosage system. Some medicines were supplied outside of the monitored dosage system and it was when this occurred that there were more issues with recording. For example, not all medicines were signed into the home and not all had amounts carried forward to the next medication administration record. This would make it difficult to audit stock properly. Codes were used when medication was omitted but these were not consistently defined. Sometimes it was recorded that the resident was asleep and they missed their medication. There was no evidence that this was given later or that the GP had been informed that medication was regularly being missed. The GP may be able to prescribe the medication to be given at a different time more in keeping with the residents routine. There were four residents for which the medication administration records showed gaps in administration. We were told that this was due to staff awaiting instructions Care Homes for Older People Page 15 of 32 Evidence: from the hospital or GPs, as their medication regimes had been changed. We accepted this was not due to the home running out of medication. The situation needs to be resolved quickly for the residents. Handwritten entries on the MAR did not consistently include the full instructions and were missing a witness signature. It is always good practice to have a witness signature to avoid mistakes being made. Changes had also been made mid-cycle but there was no signature or reason why, for example on the GPs instructions. One resident was prescribed Furosemide 40mg tablets, one twice a day, however, it was noted they only received this once a day and the late afternoon dose had been crossed through by staff. There was no explanation for this change. One residents medication had been changed mid-cycle to another type of drug but instead of drawing a line through this, signing and dating the change and writing the new medication on a separate line, staff wrote the new medication and instructions in the same box as the old and carried on the administration signatures. This was very confusing. One resident was prescribed a topical skin care product but there were sections of the MAR where staff had placed a tick rather than signed that it had been applied. The controlled drugs book had a stock entry for a particular controlled drug but we were told that this had been returned to the pharmacy. The book needs to be updated when checked with the pharmacy. Although not required to, the home maintained a record of Haloperidol medication for one resident in the controlled drugs book. However, the book states that 18 tablets remain in stock but staff advised that these were returned to the pharmacy. This section also needs updating. Some controlled drugs were no longer used by specific residents and need returning to the pharmacy. The room where medication was stored was small and cluttered with other items. There were no fridge temperature records. Topical and oral products need separating. It was noted that paracetamol tablets, for use when required, were dispensed in the monitored dosage systems. This led to a lot of waste and the staff were advised to ask the pharmacist to look at alternative arrangements. During the writing of this report, this had been addressed with the GP. Care Homes for Older People Page 16 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were some recreational activities available for people, although this is an area that could be improved. This would enhance the quality of life for people living in the home, especially those people with dementia. The home met peoples nutritional needs by providing well presented and well cooked meals. Evidence: There was evidence of some activities provided for people, although comments from residents indicated that the home had not got it quite right for everyone yet. People told us that a visiting entertainer came to play the accordion, they enjoyed watching television and friends and relatives could visit at any time. The manager told us that seasonal activities were planned and special dates celebrated throughout the year especially residents birthdays. This was confirmed in a discussion with a relative, they had a party there last week and it was the happiest she had been in a while. Staff also helped residents to keep in touch with relatives by phone and supported spouses to have a meal with their loved one. One person told us they had a newspaper delivered daily. Care Homes for Older People Page 17 of 32 Evidence: Staff helped people plan their days television and said it was possible to arrange volunteers to escort people to church and local groups. Some residents had bird feeders outside their bedroom windows to enable them to view local species. However, there was limited activities recorded in care files and some residents told us they would like to see more opportunities for recreation. There could also be more occupational stimulation for people with dementia. Comments were, I just watch television, theres not a lot going on but the staff are very good, theres no activities in the home, friends pop in and we dont have a lot (activities). Out of the six surveys received from residents, one stated there were enough activities, always, three said this was, usually, one person said, sometimes and the sixth person left this section blank. Although the choice of activities could be improved there was evidence that people could make choices about aspects of their lives, for example, where to sit and have their meals, the times of rising and retiring and the meals provided. Some comments were, I prefer to stay in my room, you can go to bed whenever - its not regimented, I have whiskey in my tea in a morning and Im an early bird to rise and to bed as I used to work on a farm. People generally liked the food provided and said they had plenty to eat and drink. One person did comment that there could be more variety. Alternatives were provided for each meal and special diets were catered for. Care Homes for Older People Page 18 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People told us they received the care they needed, however, there has been one occasion when care has fallen short of expectations and medical attention not sought promptly. This led to a complaint, a safeguarding investigation and recommendations for improving practice. Evidence: The home had a complaints policy and procedure which was on display. Staff spoken with were aware of what to do if concerns were raised with them and residents named the provider or other staff members as the people they would speak with if they were unhappy. Since the last inspection in May this year, the home has received two complaints. These were documented and investigated. One complainant had e-mailed the home to say that they were satisfied with the findings of the investigation. The local authority received a complaint about care issues affecting one resident, which has been investigated. The home had a copy of the multi-agency policy and procedure for safeguarding adults from abuse. The management team has completed training with the local authority specifically for the managers role in alerting and investigating issues of concern. The manager confirmed that all staff had received some form of safeguarding training. This could be in the form of DVD training and questionnaires or more in depth training with the local authority. Care Homes for Older People Page 19 of 32 Evidence: We discussed with the manager one incident that had occurred in which a resident had sustained an injury. The manager advised she thought it was due to the way staff members had completed a moving and handling technique despite their training. This had not been referred to the local authority and the manager was advised to discuss this with the safeguarding team. The Care Quality Commission had also not been notified about the incident. The local authority received three safeguarding referrals since the last inspection and carried out investigations. They found that no abuse had occurred, however, they made recommendations about obtaining prompt medical advice and improving documentation. One of the safeguarding investigations related to the death of a resident. It was investigated by the police and social services resulting in an inquest where the findings were that the resident had died from natural causes. The home took appropriate action regarding the failure of a staff member to act in accordance with the homes policies and procedures. Care Homes for Older People Page 20 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided a clean and warm environment for people, although the conservatory corridor requires updating. This would enhance the home for people living there. Evidence: Since the last inspection the front lounge, dining room and four bedrooms have been redecorated. The dining room is to have a new carpet next week. Following this second site visit the manager forwarded to us a three year maintenance plan, which indicated dates for ongoing redecoration and refurbishment. The conservatory corridor is in need of repair in some places as water was seen dripping in due to the heavy rain, and the carpet is in need of replacement. However, the home was clean and tidy and there were no malodours. The homes annual quality assurance assessment (AQAA) states the corridor is due to be widened to include more seating area in the next twelve months. There were a number of communal rooms for people to sit in and all were nicely decorated. One visitor told us they liked to sit in the small sitting room for private chats with their relative. The home had nineteen single bedrooms and three shared bedrooms. In total, eleven bedrooms have en-suite facilities. Bedrooms were personalised to varying degrees Care Homes for Older People Page 21 of 32 Evidence: dependent on the choice and taste of the occupants. The bedrooms off the conservatory corridor had a sky-light for a window so it was not possible for the occupant to see outside. One resident spoken with stated they liked their room but sat in the corridor so they could watch the world go by. There are plans to alter these bedrooms in the future. One resident told us they liked the home very much and enjoyed sitting near the front door in the warmer weather, others liked to sit in the garden or the courtyard for fresh air. Comments about the home were, its really a very good place, my bedroom is very nice - yes I like the home, we are well looked after, its friendly and the home is clean and tidy. The dining room was small and had three tables and chairs set out nicely with table cloths and condiments. The room was bright and warm. People told us they had a choice of where to sit for their meals and some chose to remain in the lounges or in their bedrooms. Two sittings are organised for the dining room when required. The home had two assisted bathrooms, a shower room and sufficient toilets within easy access. The shower room included a toilet, which had a window onto the corridor. Although required for the natural light, and was of frosted glass, the window posed a privacy issue, as it was possible to see in when the occupant was using the toilet. The manager advised that a blind was available and should be positioned down all the time. An alternative or addition to the blind may be more suitable to maintain privacy and dignity. The staff used a work station in the conservatory corridor and care plans were secured in a locked cabinet in this area. Any private conversations or telephone calls would need to be carried out in the upstairs office. Linen towels were used in communal bathrooms and toilets, which can cause the spread of infection and should be changed to paper towels. The laundry contains two commercial washing machines with a sluice facility and two commercial driers. People spoken with were happy with the laundry service. Care Homes for Older People Page 22 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are staff in sufficient numbers, a good recruitment system and a staff training programme in place. There has been an episode when a staff member has not put their training into practice and this placed a resident at risk. Evidence: The homes Annual Quality Assurance Assessment (AQAA) states that there has been an increase to the staffing hours available in the home from 453 to 507 hours per week. On the day of the site visit there were three care staff and a care manager during the day and two care staff for the night shift. We were told that there were usually four care staff members and a care manager during the day. We were told that the registered manager is supernumerary and is on the premises most days. There are sufficient catering and domestic staff. Comments from residents about the staff team were, they are all so very good, the staff are very good - they look after me, the staff are alright - there are no problems there at all, they help all the family to feel that everyone is important, they are very kind and patient and the helpers are very good. People told us that buzzers were answered quickly and staff were observed going about their work in a calm way. The home had a training plan in place that included mandatory training completed by distance learning and external facilitators. A training manager had recently been Care Homes for Older People Page 23 of 32 Evidence: appointed to oversee the training programme. There were also care managers that had completed a, train the trainer course in moving and handling so were able to train other carers. Despite the first aid training, one staff member did not carry out their training nor followed policies and procedures. The staff member did not listen to a resident when they stated they were ill. The local authority investigated the incident as a complaint. Staff administering medication had completed a safe handling of medication course and three additional staff were progressing through the course. Safeguarding of adults from abuse was also included in the plan and all staff had had some form of training on the subject such as watching a DVD. Others had attended a local authority awareness session on local procedures. Eleven out of sixteen care staff had gained a national vocational qualification in care at levels 2 or 3. This was a very good achievement and exceeded the standard. There was evidence of service specific training that various staff had completed. For example, dementia care, Parkinsons disease, stroke awareness, continence promotion, nutrition for elderly people, diabetes, communication and death and dying. The manager and three senior staff had completed mental capacity legislation and deprivation of liberty safeguards training. New staff completed induction booklets produced by an external organisation. To improve, the induction should evidence competence of the new staff member rather than a tick for each section and the signature of the assessor. The homes staff recruitment process evidenced that checks were carried out prior to the start of employing people. These included application forms, gaps in employment, obtaining references and carrying out police checks. This helped to ensure that only appropriate people were employed to work with vulnerable adults. Care Homes for Older People Page 24 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite intentions to run the home in the best interests of the people living there, shortfalls in risk management, recording, medication practices and staff supervision have compromised this. Evidence: One of the partners registered as the provider is also the registered manager. The registered manager has many years experience in care. She appointed a day to day manager for the home a year ago but this didnt work to plan so she has returned to providing more hands on management in the home. Staff reported that the registered manager was supportive and approachable. Since the last inspection the way staff communicate issues from one shift to the next has improved. A new daily recording sheet means that staff have to comment on each resident to provide incoming staff with any relevant information. The home has a quality assurance system that includes questionnaires and audits. We Care Homes for Older People Page 25 of 32 Evidence: were told that surveys were sent out to residents and their relatives this year and results checked so they can address any shortfalls. To improve, the home could send surveys to professionals and staff to gain a broader view of the service provided. We were told that this had happened in the past. Some audits should be more thorough to ensure that issues such as medication practices and health and safety are identified quickly and addressed. The management of residents finances had not changed since the last inspection on 19th May 2009. The inspection report from that visit stated, robust systems are in place to ensure the security, accountability and safe-keeping of all residents valuables and money. There was evidence that staff had received some formal one to one supervision with their line manager but documentation showed this was limited to between one and three sessions in the last year. We were told that supervision did take place every two months but the supervision log could not be located to evidence this fully. Staff should receive a minimum of six supervision sessions to enable them the opportunity to discuss issues and provide the supervisor with the time to monitor their work and discuss training needs. Two staff members stated in surveys that they received, regular support. There were some health and safety issues that required addressing quickly and these were discussed with the manager. There was some concern that two staff had not followed moving and handling guidance when supporting a resident into bed and this was being checked out. One resident had bed rails that were not appropriate for the particular bed. This made them unsafe and a risk assessment must be carried out quickly to decide whether they are required and if so, ensure a correct match between the resident, the bed and the rails. Care Homes for Older People Page 26 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The care plans must cover 31/03/2010 all needs identfied in assessments and be updated consistently when needs changed. This will ensure that staff have up to date information about how to provide care and ensure it is not missed. 2 8 12 Residents requests and wishes about access to health care professionals must be listened to and taken into account. This will instill confidence in residents and their relatives that their needs will be met. 31/03/2010 3 9 12 Medication, including skin 31/03/2010 preparations, eye drops and those as and when needed must be given as prescribed. This will make sure that people receive their medicines correctly and the Care Homes for Older People Page 28 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action treatment of their medical condition is not affected. 4 12 16 The social stimulation needs of people must be assessed and met, especially in relation to their dementia. This will ensure staff are aware of peoples previous interests and hobbies and current ability to participate so that activites can be planned and tailored to meet needs. 5 27 18 Staff must follow guidance and put their skills and training into practice. This will ensure that people are cared for and supported safely. 6 38 13 Residents with bed rails in use must have a thorough risk assessment in place. This will help to determine whether the rails are required and which type are suitable for the resident and the bed in use. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 31/03/2010 31/03/2010 31/03/2010 1 3 The home should, prior to admission, obtain assessments Page 29 of 32 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations completed by care management for people funded by the local authority. This will provide more information to enable staff to decide if the persons needs can be met in the home. 2 7 Care plans should be signed by the person formulating them and where possible by the resident or their representative. This will help to evidence that people have seen and agree the contents. Monitoring records, including weight and nutritional intake, should be completed thoroughly. This will provide visiting professionals with information they need to manage treatment and advice. The GP should be contacted when people regularly decline to take their medication or it is omitted because of their daily routine of waking late or retiring early. This will provide them with the opportunity of reviewing the dose or times to ensure people receive their medication. The temperature of the fridge storing medicines should be taken to evidence that medication is stored correctly. Medicines no longer in use should be returned to the pharmacy unless there are special instructions to keep them in the home longer. All medicines should be signed into the home and written entries onto the MAR and changes mid-cycle should include full instructions and have a witness signature. This will help to avoid mistakes. In light of comments about activities and limited recording evidence, staff should speak with residents and find out how they can improve what is available for people. Staff should continue to follow recomendations and improve practice to ensure that residents are protected and receive the care they need. Consideration should be given to updating aspects of the environment, including the corridor near the entrance area. Paper towels should be installed in communal bathrooms and toilets to prevent the spread of infection. The induction programme should evidence the competence of new staff. This will provide the opportunity for staff to test out their knowledge and for their answers to the Page 30 of 32 3 8 4 9 5 6 9 9 7 9 8 12 9 18 10 11 12 19 26 30 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations questions to be in written form and seen by the assessor. 13 30 The training log should include service specific training as well as mandatory training that staff complete. This will provide clear records and help to audit training needs. The home should send surveys to professional visitors and staff to gain a broader view of the service provided and should be more thorough when completing audits to ensure that issues such as medication practices and health and safety are identified quickly and addressed. Care staff should receive a minimum of six, formal, one to one supervision sessions per year. This will enable them to discuss issues of concern and also enable their line manager to monitor their work. A system should be put in place to remind staff to visually check bed rails during each use and to ensure they remain well maintained and safe to use. 14 33 15 36 16 38 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. 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